- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.67 / $3,467.67 / $4,001.15
| Professional | | $3,467.67 | $3,467.67 | $4,001.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,697.47 / $4,697.47 / $5,222.83
| Facility | | $4,697.47 | $4,697.47 | $5,222.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,429.16 / $3,429.16 / $4,383.24
| Professional | | $3,429.16 | $3,429.16 | $4,383.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,697.47 / $4,697.47 / $5,222.83
| Facility | | $4,697.47 | $4,697.47 | $5,222.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,429.16 / $3,429.16 / $4,383.24
| Professional | | $3,429.16 | $3,429.16 | $4,383.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,200.92 / $5,661.89 / $5,908.53
| Professional | | $3,200.92 | $5,661.89 | $5,908.53 |